Online Referral Form Test

Opening Times: 9:15am - 5.30pm (Mon-Fri)

47 Gipsy Lane, Leicester LE4 6RD | Directions

Call Us: 0116 268 1444

Online Referral Form

Patient Details

Patient Name:

Patient DOB:

Patient Address:

Patient Email:

Patient Telephone:

Referring Dentist Details

Referring Practice Name:

Referring Dentist:

Referring Practice Telephone:

Referring Practice Email:

Referring Practice Address:

Patient Medical History

Please provide details of the patient’s medical history and any medication we should be made aware of:

Medical History Details:

By clicking the box, you confirm that there is no medical reason to prevent this patient receiving a Cone Beam CT Scan

By clicking the box, you confirm acceptance that the service is for scanning of the patient only, and not for reporting on the scan or OPG.

Referral Information

Scan Type:

CBCT Scan OPG

CBCT Scan Details:

Section Arch Details:

Please provide reason for referral:

Please be aware the CBCT is located on the first floor of our practice and you confirm that the patient is able to climb stairs

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Our Practice

Gipsy Lane Dental

47 Gipsy Lane, Leicester, LE4 6RD
0116 268 1444

reception@gldental.co.uk
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Opening Times

Monday:	9.15am - 5.30pm
Tuesday:	9.15am - 5.30pm
Wednesday:	9.15am - 5.30pm
Thursday:	9.15am - 5.30pm
Friday:	9.15am - 5.30pm
Saturday:	Closed
Sunday:	Closed

Latest News

Gipsy Lane Dental - New Website Live

5th May 2017

We are please to launch our new Gipsy...